<%-- 
    Document   : jspGestionarNino
    Created on : 19/09/2011, 11:01:14 PM
    Author     : yohanna
--%>

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<html>
    <head>
        <meta http-equiv="Content-Type" content="text/html; charset=UTF-8">
        <title>JSP Page</title>
    </head>
    <body>
        <form class="jotform-form" action="http://spanish.jotform.com/submit.php" method="post" name="form_12575003292" id="12575003292" accept-charset="utf-8">
  <input type="hidden" name="formID" value="12575003292" />
  <div class="form-all">
            <h2 class="style1">Gestionar niño</h2>
			<h2 id="header_1" class="style1"><span class="style2">Ingrese la
	identificacion del niño: </span>
          <input type="text" class="form-textbox validate[Alfanumérico]" id="input_18" name="q3_codigo0" size="20" />&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
			<input name="Consultar" type="button" value="Consultar" /></h2>
	<ul class="form-section">
      <li class="form-line" id="id_3">
        <label class="form-label-left" id="label_3" for="input_3"> Código </label>
		<span class="style2">
          <input type="text" class="form-textbox validate[Alfanumérico]" id="input_3" name="q3_codigo" size="20" style="width: 128px" /></span></li>
		<li class="form-line" id="id_4"></li>
		<li class="form-line" id="id_4">
		<label class="form-label-left" id="label_4" for="input_4">Identificación
		</label>
		<input type="text" class="form-textbox validate[Numérico]" id="input_4" name="q4_identificacion" size="20" /><div id="cid_4" class="form-input">
&nbsp;</div>
		</li>
		<li class="form-line" id="id_18">
		<label class="form-label-left" id="label_18" for="input_18">Nombre completo
		</label>
		<div id="cid_18" class="form-input">
			<span class="form-sub-label-container">&nbsp;<label class="form-sub-label" for="first_18" id="sublabel_first">Nombre&nbsp;&nbsp;
			<input class="form-textbox" type="text" size="10" name="q18_nombreCompleto[first]" id="first_18" style="width: 162px" />&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
			<label class="form-sub-label" for="last_18" id="sublabel_last">Apellido
			</label>&nbsp;&nbsp;&nbsp; </label>
			<input class="form-textbox" type="text" size="15" name="q18_nombreCompleto[last]" id="last_18" style="width: 154px" />
			<br />
			</span></div>
		</li>
		<li class="form-line" id="id_7">
		<label class="form-label-left" id="label_7" for="input_7">Fecha de nacimiento
		</label>
		<div id="cid_7" class="form-input">
			<span class="form-sub-label-container">
			<select class="form-dropdown" name="q7_fechaDe7[day]" id="input_7_day">
			<option></option>
			<option value="31">31</option>
			<option value="30">30</option>
			<option value="29">29</option>
			<option value="28">28</option>
			<option value="27">27</option>
			<option value="26">26</option>
			<option value="25">25</option>
			<option value="24">24</option>
			<option value="23">23</option>
			<option value="22">22</option>
			<option value="21">21</option>
			<option value="20">20</option>
			<option value="19">19</option>
			<option value="18">18</option>
			<option value="17">17</option>
			<option value="16">16</option>
			<option value="15">15</option>
			<option value="14">14</option>
			<option value="13">13</option>
			<option value="12">12</option>
			<option value="11">11</option>
			<option value="10">10</option>
			<option value="9">9</option>
			<option value="8">8</option>
			<option value="7">7</option>
			<option value="6">6</option>
			<option value="5">5</option>
			<option value="4">4</option>
			<option value="3">3</option>
			<option value="2">2</option>
			<option value="1">1</option>
			</select>
			<label class="form-sub-label" for="input_7_day" id="sublabel_day">Día
			</label></span><span class="form-sub-label-container">
			<select class="form-dropdown" name="q7_fechaDe7[month]" id="input_7_month">
			<option></option>
			<option value="Enero">Enero</option>
			<option value="Febrero">Febrero</option>
			<option value="Marzo">Marzo</option>
			<option value="Abril">Abril</option>
			<option value="Mayo">Mayo</option>
			<option value="Junio">Junio</option>
			<option value="Julio">Julio</option>
			<option value="Agosto">Agosto</option>
			<option value="Septiembre">Septiembre</option>
			<option value="Octubre">Octubre</option>
			<option value="De noviembre">De noviembre</option>
			<option value="Diciembre">Diciembre</option>
			</select>
			<label class="form-sub-label" for="input_7_month" id="sublabel_month">Mes
			</label></span><span class="form-sub-label-container">
			<select class="form-dropdown" name="q7_fechaDe7[year]" id="input_7_year">
			<option></option>
			<option value="2015">2015</option>
			<option value="2014">2014</option>
			<option value="2013">2013</option>
			<option value="2012">2012</option>
			<option value="2011">2011</option>
			<option value="2010">2010</option>
			<option value="2009">2009</option>
			<option value="2008">2008</option>
			<option value="2007">2007</option>
			<option value="2006">2006</option>
			<option value="2005">2005</option>
			<option value="2004">2004</option>
			<option value="2003">2003</option>
			<option value="2002">2002</option>
			<option value="2001">2001</option>
			<option value="2000">2000</option>
			<option value="1999">1999</option>
			<option value="1998">1998</option>
			<option value="1997">1997</option>
			<option value="1996">1996</option>
			<option value="1995">1995</option>
			<option value="1994">1994</option>
			<option value="1993">1993</option>
			<option value="1992">1992</option>
			<option value="1991">1991</option>
			<option value="1990">1990</option>
			<option value="1989">1989</option>
			<option value="1988">1988</option>
			<option value="1987">1987</option>
			<option value="1986">1986</option>
			<option value="1985">1985</option>
			<option value="1984">1984</option>
			<option value="1983">1983</option>
			<option value="1982">1982</option>
			<option value="1981">1981</option>
			<option value="1980">1980</option>
			<option value="1979">1979</option>
			<option value="1978">1978</option>
			<option value="1977">1977</option>
			<option value="1976">1976</option>
			<option value="1975">1975</option>
			<option value="1974">1974</option>
			<option value="1973">1973</option>
			<option value="1972">1972</option>
			<option value="1971">1971</option>
			<option value="1970">1970</option>
			<option value="1969">1969</option>
			<option value="1968">1968</option>
			<option value="1967">1967</option>
			<option value="1966">1966</option>
			<option value="1965">1965</option>
			<option value="1964">1964</option>
			<option value="1963">1963</option>
			<option value="1962">1962</option>
			<option value="1961">1961</option>
			<option value="1960">1960</option>
			<option value="1959">1959</option>
			<option value="1958">1958</option>
			<option value="1957">1957</option>
			<option value="1956">1956</option>
			<option value="1955">1955</option>
			<option value="1954">1954</option>
			<option value="1953">1953</option>
			<option value="1952">1952</option>
			<option value="1951">1951</option>
			<option value="1950">1950</option>
			<option value="1949">1949</option>
			<option value="1948">1948</option>
			<option value="1947">1947</option>
			<option value="1946">1946</option>
			<option value="1945">1945</option>
			<option value="1944">1944</option>
			<option value="1943">1943</option>
			<option value="1942">1942</option>
			<option value="1941">1941</option>
			<option value="1940">1940</option>
			<option value="1939">1939</option>
			<option value="1938">1938</option>
			<option value="1937">1937</option>
			<option value="1936">1936</option>
			<option value="1935">1935</option>
			<option value="1934">1934</option>
			<option value="1933">1933</option>
			<option value="1932">1932</option>
			<option value="1931">1931</option>
			<option value="1930">1930</option>
			<option value="1929">1929</option>
			<option value="1928">1928</option>
			<option value="1927">1927</option>
			<option value="1926">1926</option>
			<option value="1925">1925</option>
			<option value="1924">1924</option>
			<option value="1923">1923</option>
			<option value="1922">1922</option>
			<option value="1921">1921</option>
			<option value="1920">1920</option>
			</select>
			<label class="form-sub-label" for="input_7_year" id="sublabel_year">Año<br />
			</label></span></div>
		</li>
		<li class="form-line" id="id_8">
		<label class="form-label-left" id="label_8" for="input_8">Sexo </label>
		</li>
		<li class="form-line" id="id_8">
		<div id="cid_8" class="form-input">
			<div class="form-single-column">
				<p class="style3">
				<span class="form-radio-item" style="clear:left;">
				<input type="radio" class="form-radio" id="input_8_0" name="q8_sexo" value="Masculino" />
				<label for="input_8_0">Masculino</label></span></p>
				<p class="style3">
				<span class="form-radio-item" style="clear:left;">
				<label for="input_8_0">&nbsp;</label></span><span class="clearfix"></span><span class="form-radio-item" style="clear:left;"><input type="radio" class="form-radio" id="input_8_1" name="q8_sexo" value="Femenino" />
				<label for="input_8_1">Femenino </label></span>
				<span class="clearfix"></span></p>
			</div>
		</div>
		</li>
		<li class="form-line" id="id_9">
		<label class="form-label-left" id="label_9" for="input_9">Fecha Ingreso
		</label>
		<div id="cid_9" class="form-input">
			<span class="form-sub-label-container">
			<input class="noDefault form-textbox" id="day_9" name="q9_fechaIngreso[day]" type="text" size="2" maxlength="2" value="" />
            -
            <label class="form-sub-label" for="day_9" id="sublabel_day">Día
			</label></span><span class="form-sub-label-container">
			<input class="form-textbox" id="month_9" name="q9_fechaIngreso[month]" type="text" size="2" maxlength="2" value="" />
            -
            <label class="form-sub-label" for="month_9" id="sublabel_month">Mes
			</label></span><span class="form-sub-label-container">
			<input class="form-textbox" id="year_9" name="q9_fechaIngreso[year]" type="text" size="4" maxlength="4" value="" />
            at
            <label class="form-sub-label" for="year_9" id="sublabel_year">Año
			</label></span><span class="form-sub-label-container">
			<input class="form-textbox" id="hour_9" name="q9_fechaIngreso[hour]" type="text" size="2" maxlength="2" value="" />
            /
            <label class="form-sub-label" for="hour_9" id="sublabel_hour">Hora
			</label></span><span class="form-sub-label-container">
			<input class="form-textbox" id="min_9" name="q9_fechaIngreso[min]" type="text" size="2" maxlength="2" value="" />
			<label class="form-sub-label" for="min_9" id="sublabel_minutes">Acta
			</label></span><span class="form-sub-label-container">
			<select class="form-dropdown" id="ampm_9" name="q9_fechaIngreso[ampm]">
			<option value="AM">AM</option>
			<option value="PM">PM</option>
			</select> <label class="form-sub-label" for="ampm_9">&nbsp;&nbsp;&nbsp;
			</label></span><span class="form-sub-label-container">
			<img alt="Elija una fecha" id="input_9_pick" src="http://spanish.jotform.com/images/calendar.png" align="absmiddle" />
			<label class="form-sub-label" for="input_9_pick">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
			<br />
&nbsp;</label></span></div>
		</li>
		<li class="form-line form-line-column" id="id_10">
		<label class="form-label-top" id="label_10" for="input_10">Peso(cm):&nbsp;
		</label>
		<input type="text" class="form-textbox validate[Numérico]" id="input_10" name="q10_pesocm" size="20" /><div id="cid_10" class="form-input-wide">
&nbsp;</div>
		</li>
		<li class="form-line form-line-column" id="id_11">
		<label class="form-label-top" id="label_11" for="input_11">Altura(cm):&nbsp;
		</label>
		<input type="text" class="form-textbox validate[Numérico]" id="input_11" name="q11_alturacm" size="20" /><div id="cid_11" class="form-input-wide">
&nbsp;</div>
		</li>
		<li class="form-line" id="id_12">
		<label class="form-label-left" id="label_12" for="input_12">Fecha Salida
		</label>
		<div id="cid_12" class="form-input">
			<span class="form-sub-label-container">
			<input class="form-textbox" id="day_12" name="q12_fechaSalida[day]" type="text" size="2" maxlength="2" value="15" />
            -
            <label class="form-sub-label" for="day_12" id="sublabel_day">Día
			</label></span><span class="form-sub-label-container">
			<input class="form-textbox" id="month_12" name="q12_fechaSalida[month]" type="text" size="2" maxlength="2" value="09" />
            -
            <label class="form-sub-label" for="month_12" id="sublabel_month">Mes
			</label></span><span class="form-sub-label-container">
			<input class="form-textbox" id="year_12" name="q12_fechaSalida[year]" type="text" size="4" maxlength="4" value="2011" />
            at
            <label class="form-sub-label" for="year_12" id="sublabel_year">Año
			</label></span><span class="form-sub-label-container">
			<input class="form-textbox" id="hour_12" name="q12_fechaSalida[hour]" type="text" size="2" maxlength="2" value="20" />
            /
            <label class="form-sub-label" for="hour_12" id="sublabel_hour">Hora
			</label></span><span class="form-sub-label-container">
			<input class="form-textbox" id="min_12" name="q12_fechaSalida[min]" type="text" size="2" maxlength="2" value="27" />
			<label class="form-sub-label" for="min_12" id="sublabel_minutes">Acta
			</label></span><span class="form-sub-label-container">
			<select class="form-dropdown" id="ampm_12" name="q12_fechaSalida[ampm]">
			<option value="AM">AM</option>
			<option value="PM">PM</option>
			</select> <label class="form-sub-label" for="ampm_12">&nbsp;&nbsp;&nbsp;
			</label></span><span class="form-sub-label-container">
			<img alt="Elija una fecha" id="input_12_pick" src="http://spanish.jotform.com/images/calendar.png" align="absmiddle" /><br />
			</span></div>
		</li>
		<li class="form-line form-line-column" id="id_13">
		<label class="form-label-top" id="label_13" for="input_13">Comedor&nbsp;
		</label>
		<select class="form-dropdown" style="width:150px" id="input_13" name="q13_comedor">
		<option selected="selected">Seleccione Comedor</option>
		<option value="Opción 1 ">Las vegas</option>
		<option value=" Opción 2 ">3 de junio</option>
		<option value=" Opción 3">El progreso</option>
		<option>Las primeveras</option>
		<option>vista hermosa</option>
		</select><br />
		<div id="cid_13" class="form-input-wide">
&nbsp;</div>
		</li>
		<li class="form-line form-line-column" id="id_14">
		<label class="form-label-top" id="label_14" for="input_14">Medico
		</label>
		<select class="form-dropdown" style="width:150px" id="input_14" name="q14_medico">
		<option>Jose Armando Muñoz Barrio</option>
		<option selected="selected">Seleccione Medico</option>
		<option value="Opción 1 ">Juan Sebastian Dominguez</option>
		<option value=" Opción 2 ">Yurys Crespo</option>
		<option value=" Opción 3">Ana Sofia Vergara</option>
		</select>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
		<button id="input_15" type="submit" class="style4">&nbsp;Historiales
            	</button>
		<div id="cid_14" class="style1">
&nbsp;<br />
			<br />
			<br />
			<input name="Nuevo" type="submit" value="Nuevo" style="width: 65px" />&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
<input name="Editar" type="submit" value="Editar" style="height: 26px" />&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
<input name="Submit2" type="submit" value="Actualizar" />&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
<input name="Submit1" type="submit" value="Salir" style="width: 71px" />&nbsp;&nbsp;&nbsp;
<input name="Submit3" type="submit" value="Guardar" /></div>
		</li>
		<li style="display:none">Should be Empty:
        <input type="text" name="website" value="" /> </li>
    </ul>
		<p>&nbsp;</p>
  </div>
  <input type="hidden" id="simple_spc" name="simple_spc" value="12575003292" />
  <script type="text/javascript">
  document.getElementById("si" + "mple" + "_spc").value = "12575003292-12575003292";
  </script>
</form>

        <h1>Hello World!</h1>
    </body>
</html>
